Makindo Medical Notes

The clinical presentation of D-lactic acidosis is characterized by episodes of encephalopathy and metabolic acidosis

Not a drink yet drunk
Gap, buzz from fermenting funk
Much time in ORs
Slurred speech, stupor, all befall
Carbs bypass to large from small
@DrCindyCooper

About

• D-lactate is a stereoisomer of L-Lactate
• L-lactic acid is the main entity involved in lactic acidosis in humans

Aetiology

• Short bowel syndrome eg multi-resection.
• Malabsorption or jejuno-ileal bypass surgery
• Carbs presented to colon are metabolized to D-lactate

Clinical

• Stupor, inebriation, coma
• Delirium, ataxia, and slurred speech
• Altered mental status, psychosis, or even coma

Investigations

• ABG: high anion gap metabolic acidosis
• D Lactate not measured by standard lactate assay. If measured D-lactate concentration of >3 mmol/L is used to define the diagnosis

Management

• Intravenous bicarbonate can be used with fluid hydration to correct acidemia. Lactated ringer should be avoided as it contains both D- and L-lactate.
• During an acute episode, enteral carbohydrates should be avoided. Not only will this decrease the D-lactate due to lack of substrate but also the lactate-producing bacteria will starve and die in the absence of a food source
• Carbohydrates can be supplemented parenterally and thiamine supplementation should be considered to cover for the additional pyruvate dehydrogenase activity, especially in the cerebellum.
• Oral antibiotics that are poorly absorbed are most effectively used locally in the gut—these include clindamycin, vancomycin, neomycin, and kanamycin.
• Haemodialysis has been used to rapidly clear D-lactate from the plasma

References

• Review of D Lactic acidosis 2016
• Review of D Lactic acidosis